DMAS and KePRO Your Key to PA. 2 Program Changes and Updates Check out the Medicaid Memos and Manuals on line It’s easy: Go to the DMAS website at www.dmas.virginia.gov.

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Presentation on theme: "DMAS and KePRO Your Key to PA. 2 Program Changes and Updates Check out the Medicaid Memos and Manuals on line It’s easy: Go to the DMAS website at www.dmas.virginia.gov."— Presentation transcript:

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DMAS and KePRO Your Key to PA

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2 Program Changes and Updates Check out the Medicaid Memos and Manuals on line It’s easy: Go to the DMAS website at and click on the link to Providers Serviceswww.dmas.virginia.gov or Go to the KePRO website at

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4 Submitting PA Requests via iEXCHANGE The preferred method of submission for PA requests is through iEXCHANGE at Providers can use iEXCHANGE to submit requests 24 hours a day, seven days a week Registration is required and once completed, providers can expect to receive their iEXCHANGE user login and password by within 10 business days

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7 Submitting PA Requests via Fax Updated PA request fax forms are now posted on the DMAS and KePRO websites The forms have been updated based upon provider feedback, and are available in two formats: (1) a PDF version that providers can download and complete manually; and, (2) an editable Word version, that allows providers to save the form and input responses directly. Use of editable version of the PA request form will expedite processing

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8 Submitting PA Requests via FAX When submitting by fax and/or mail, providers must use the updated fax forms and should include all relevant clinical information in the Severity of Illness (SI) and Intensity of Service (IS) boxes Please do not state “see attached” or “meets criteria,” and do not send attachments with the fax forms, except as noted in fax form instructions KePRO is unable to alter any information submitted on PA requests Providers are responsible for providing accurate and correct information on their PA requests

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9 Submitting PA Requests for Waivers The preferred method of submission for PA requests for waiver services is through iEXCHANGE; however, requests may be submitted via fax, telephone, or mail Please note that PA requests for waiver enrollments must be submitted by fax or mail and must include a thoroughly completed copy of the individual’s Uniform Assessment Instrument (UAI) screening form PA requested “from” and “through” service dates are required for all PA submissions. However, for certain waiver services, an “open” through date (12/31/9999) is no longer acceptable Under KePRO, all dates entered must be “valid” and the new open through date format is equal to six (6) years beyond the “from” date of service. The through date for “open” waiver PAs will be systematically auto-renewed by KePRO prior to the PA expiration date. This new “open” end-date change applies to newly added and/or updated prior authorizations. Providers are not required to change existing waiver prior authorizations (e.g., those on file with a “12/31/9999” authorized through date)

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10 Submitting Additional Information n To submit additional information on an open case iEXCHANGE Providers may submit additional information through iEXCHANGE by choosing "add to comments." (NOTE: The "extend case" feature is to be used when requesting additional days of coverage except for inpatient med/surg admissions.). Whenever a provider adds to comments, this puts the case back in the nurse review queue FAX / PHONE Providers may receive a notice from KePRO requesting additional information. Providers should submit additional information by following the instructions received from KePRO on the "fax-back" notice

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11 Receiving a PA Number Providers may obtain the PA number from the following sources: n iEXCHANGE – go to n Fax received from KePRO for requests faxed or phoned in (except full authorizations for EDCD/AIDS waiver services) n DMAS web-based ARS at n Medicall ( or ) n PA notification letters sent to the provider address on file with DMAS

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12 Receiving a PA Number Once your PA request has been submitted, a case ID number will be generated. The case ID number is used to track this specific case through KePRO’s system Please note that the case ID number is not your PA number The PA number will also be posted on iEXCHANGE (and sent via fax for telephone and fax PA submissions.)

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13 Receiving a PA Number Reading numbers in iEXCHANGE Medicaid ID numbers consists of 12 digits KePRO Case ID number is 9 digits with dashes PA Number generated by the VAMMIS is 11 digits Without the correct number of digits, it will take longer to process the request

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14 Retro Reviews PA requests for retroactively eligible recipients or “retro-reviews” Requested start of care date should be entered as the first day hands-on service was provided to the individual once Medicaid eligibility was effective These “retro reviews” can also be submitted via iEXCHANGE, phone, or fax, and should include only the required clinical documentation (i.e., do not submit the entire medical record)

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15 Overlapping Dates Overlapping dates with the same provider For on-going prior authorizations, check your files and verify the dates that you already have authorized or denied before submitting your request Submit your request using the correct begin and end dates If your new PA request overlaps with an approved or denied PA that we already have on file (same recipient, same provider, same service, same or overlapping dates), your PA request will be rejected back to you to correct the begin and/or end dates

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16 Overlapping Dates Overlapping dates with another provider If your PA request overlaps with a PA from a different provider (same recipient, same service, same or overlapping dates), your PA request will be delayed. Therefore, be sure to request the correct begin and end dates

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17 ICD-9 Codes ICD-9 Diagnosis Codes For ALL prior authorization submissions, the primary ICD-9 diagnosis code (include all 5 digits, where applicable) relative to the PA requested service(s) is required unless otherwise directed. For inpatient PA requests, the admission or “working” diagnosis ICD-9 code is sufficient. (The diagnosis code provided with the inpatient PA request is not required to match with the diagnosis code billed on the inpatient claim) iEXCHANGE provides a search feature for ICD-9 and procedure codes. These codes are also available in an Excel format on the KePRO website at

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18 Procedure Codes For inpatient admissions, procedure codes are not required as part of the PA submission. If the recipient is being admitted for a planned, elective, surgical procedure, the provider must specify the procedure to be performed as part of the severity of illness or intensity of service documentation For Outpatient Services providers must identify the PA requested service(s) using the most appropriate procedure code (CPT, HCPCS, Revenue codes etc)

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19 Procedure Codes When entering a HCPCS Procedure Code through iEXCHANGE, capitalize the leading alpha character, such as "E1399" Additionally, the maximum number of procedures that can be submitted per PA is 18 (this is not a change). Therefore, any PA request (i.e., specialized wheelchairs, etc.) having over 18 lines must be submitted via a separate PA request

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20 Procedure Codes For non-emergency outpatient (NEOP) scans including MRI, PET, and CAT scans, provide the CPT code(s) that most closely matches with the physician’s order, particularly with the body part/location of scan While the CPT code requested at the time of PA is not required to match with the CPT code billed on the claim, it should match the location (body part) scanned. The number of CPT codes requested will be reflected as units on the letter from First Health Services along with the PA number. Additionally, for those scans not yet scheduled at the time of PA submission, submit the PA request with a “through date of service” up to 90 days beyond the requested service begin date. (For scan claim submissions, the provider must bill using the CPT code that matches the scan service rendered. Claim payment is based upon the CPT code billed) Please note: Imaging requests will be authorized for 90 days beginning the date KePRO is notified (unless it is a retro request)

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21 Revenue Codes For Home Health and Outpatient Rehabilitation providers, continue using the existing revenue codes; however, for PA submissions, a prefix of “R” is needed, i.e., revenue code 0421 must be entered as R0421. Please note that the R prefix is only required for the PA submission; continue to submit claims without the “R” prefix The appropriate revenue codes are listed in the DMAS Home Health Provider Manual and Rehabilitation Provider Manual (Chapter 5)

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22 Verifying Eligibility Eligibility verification avoids unnecessary delays associated with PA submissions to an incorrect payer source Providers should submit PA requests for the dates that the recipient is Medicaid Fee-For-Service eligible. Requests that are submitted for dates outside of the recipient's eligibility coverage (except for future dates where the recipient has on-going coverage) will be rejected back to the provider for correction How do I verify recipient eligibility? DMAS web-based ARS at Medicall ( or )

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23 Questions Should you have any questions regarding the prior authorization process, please send your inquiries via to or Remember, do not send PHI by unless it is sent via a secure encrypted transmission The most up-to-date PA information is posted on the DMAS Website at and the KePRO website at A pre-recorded Web-Ex training that provides an in-depth PA overview and an iEXCHANGE demo is available on the KePRO website at Providers may view this web-cast training at their convenience